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Phone: ______________________ Last Four Digits of Acct #: ______________ I declare under penalty of perjury that the information provided in this notice is true and correct to the best of my knowledge and belief. By: /s/ Craig Ari Loren, Member Transferee/Transferees Agent Date: 7/28/2011
Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. 152 & 3571.